Exam 4 - Endocrine Flashcards
Liver is the primary sournce of endogenous glucose production via what 2 processes?
glycogenolysis & gluconeogenesis
s2
what are the Hyperglycemia-producing hormones and why are they important?
- glucagon, epinephrine, growth hormone, and cortisol
- they comprise the glucose counterregulatory system and support glucose production
s3
What is the common s/e of metformin? Who is it contraindicated for?
GI side effects.
Contrainidicated with renal insufficiency.
S10
what are some facts regarding etiology of Type 2 DM?
- Accounts for >90% DM cases
- Increasingly seen in younger pts & children over the past decade
- Very underrecognized, normally present 4-7 years before diagnosed
s6
What is the initial tx for DMII?
Lifystyle changes and Metformin
S10
What are the additional therapies for DMII?
Insulin
Sulfonylurea
GLP-1 receptor agonist
Thiazolidenedione
glinide
SGLT-2 inhibitor
DPP-4 inhibitor
a- glucosidase inhibitor
Pramlintide
S10
Insulin is necessary in ____ DMI cases & ____ DMII cases
all
30%
S11
Types of insulin
- Rapid acting (Lispro, Aspart)
- Short acting (regular)
- Basal/intermediate acting (NPH, Lente)
- Long acting (Ultralente, Glargine)
S11
What is the most dangerous complication of insulin? What is it exacerbated by?
Hypoglycemia.
Exacerbated by ETOH, metformin, sulfonylureas, ACE-I’s, MAOI’s, Non-selective BB’s
S11
What does repetitive hypoglycemic episodes can lead to? What is the tx for hypoglycemia?
“Hypoglycemia unawareness”
Pt becomes desensitized to hypoglycemia and doesn’t show autonomic sx.
Neuroglycopenia ensues→fatigue, confusion, h/a, seizures, coma.
Tx: PO or IV glucose (may give SQ or IM if unconscious)
S11
What is the onset/peak/duration of short acting insulin (Human Regular, Lispro, Aspart)?
S12
What is the onset/peak/duration of intermediate insulin (Human NPH, Lente)?
S12
What is the onset/peak/duration of long acting insulin (ultralente, glargine)?
S12
Plasma insulin levels (chart)
Memorize
S12
What are the diagnostic features of DKA?
S13
What is a complication of decompensated DM? what its mortality rate?
Diabetic Ketoacidosis
mortality 1-2%
S13
DKA is more common in which type of DM? What can trigger DKA?
DKA more common in DMI, often triggered by infection/illness
S13
How does high glucose affect the renal function?
High glucose exceeds the threshold for renal reabsorption creating osmotic diuresis & hypovolemia.
S13
What causes the overproduction of ketoacids?
Tight metabolic coupling of gluconeogenesis & ketogenesis.
DKA results in excessive glucose-counterregulatory hormones, with glucagon activating lipolysis & free fatty acids→ substrates for ketogenesis.
S13
What is the treatment for DKA?
- IV volume replacement
- Insulin: Loading dose 0.1u/kg Regular + low dose infusion @ 0.1u/kg/hr
- Correct acidosis: sodium bicarb
- Electrolyte supplement: k+, phos, mag, sodium
*Correction of glucose w/o simultaneous correction of sodium may result in cerebral edema
S14
What are the characteristics of hyperglycemic hyperosmolar syndrome? What is the mortality rate of HHM?
severe hyperglycemia, hyperosmolarity & dehydration
Mortality 10-20%
S15
What are the signs and symptoms of Hyperglycemic Hyperosmolar Syndrome?
- Polyuria
- polydipsia
- hypovolemia
- HoTN
- tachycardia
- organ hypoperfusion
- Some degree of acidosis, but not DKA
Hyperosmolarity leads to coma.**
S15
What is the treatment of Hyperglycemic Hyperosmolar Syndrome?
fluid resuscitation, insulin bolus + infusion, e-lytes
S15
What happens when glucose load exceeds renal glucose absorption?
Mass solute diuresis
S15
What is the microvascular complication of DM?
Nonocclusive microcirculatory dz w/impaired blood flow autoregulation
S16
What is the neuropathic complication of DM associated w/ renal fx?
30-40% DM1, 5-10% DM2 develop ESRD. Kidneys develop glomerulosclerosis, arteriosclerosis, & tubulointerstitial disease
S16
What are the signs of DM related ESRD?
HTN, proteinuria, peripheral edema,↓GFR
S16
What causes hyperkalemia in patients with ESRD?
When GFR < 15-20, kidneys no longer clear K+, Pts become hyperkalemic & acidotic
S16
What is the treatment for ESRD?
- ESRD tx: HD, PD, kidney transplant
- ACE-I’s slow progression of proteinuria and the rate of GFR slowing
Combined kidney-pancreas transplant may prevent recurrent nephropathy
S16
What is characteristic of DM peripheral neurophathy? How does it progress?
Normally a distal symmetric diffuse sensorimotor polyneuropathy.
Starts in toes/feet, progresses proximally
S17
Loss of which fibers cause the reduction in light touch and proprioception?
large sensory & motor fibers
S17
Loss of which fibers cause the decrease in pain/temperature perception leading to neuropathic pain?
Small nerve fibers
S17
What causes the significant morbidity in someone w/ peripheral neuropathy?
Recurrent infections & amputation wounds.
S17
What medication doesn’t affect the underlying abnormality, but may relieve sx of Graves disease?
Beta Blockers
Propranolol impairs the peripheral conversion of T4 to T3
S28
What is the treatment of peripheral neuropathy?
optimal glucose control, NSAIDS, antidepressants, anticonvulsants
S17
What is diabetes related retinopathy?
- microvascular changes including vessel occlusion, dilation, ↑permeability, microaneurysms
- Visual impairment ranges from color loss to blindness
S17
What is a
General
Psych
s/s of Hyperparathyroidism?
General: Anxious
Psych: Emotionally unstable
S26 table
DM complications
What causes autonomic neuropathy?
damaged vasoconstrictor fibers, impaired baroreceptors and ineffective CV activity!
18
What are the CV and GI s/s of autonomic neuropathy?
What is the treatment?
CV: abnormal HR control (variability), vascular dynamics, resting tachycardia, orthostatic hypotension and dysrhythmias
GI: N/V, bloating, impaired secretions & mobility–> gastroparesis
Tx: glucose control, small meals, prokinetics
18
What do you emphasize in patients with DM in the preop eval?
-emphasize CV, renal, neurologic, & muscoskeletal systems
-silent ischemia is possible!
-meticulus attention to hydration, preserve RBF!
-Consider stress test if multiple cardiac risk factors and poor exercise tolerance
19
What are diabetics at risk for in regards to anesthesia?
-Arrhythmia risk d/t autonomic neuropathy
-risk for aspirations d/t gastroparesis
* hold PO hypoglycemic and noninsulin injectables
19
Who is at risk for insulinoma?
Dx is based on whipple triad..what are they?
Insulinoma- benign insulin secreted pancreatic islet tumor
-occurs 2x in women than men~ 50-60 y/o
-Whipple triad:
hypoglycemia w fasting, glucose <50 w symptoms, and symptom release w glucose
-
20
Insulinoma pt’s have high insulin levels during 48-72 hr fast (dx). What meds should you give them preop?
diaxoide, inhibits insulin release from B cells
-verapamil, phenytoin, promanalol, glucorticoids and ocreotide
-they’re at risk for hypoglycemia intraop** then hyperglycemia when tumor is removed
20
Thyroid gland is composed of 2 lobes joined by an isthmus.
Where is the thyroid gland located?
What is located on the posterior aspect of each lobe?
-The gland is affixed to the anterior & lateral trachea, with upper border just below the cricoid cartilage
-parathyroid gland located on posterior aspect of each lobe
21
What innervates the rich capillary network in the thyroid gland?
What nerves are close to it?
Adrenergic and cholinergic systems innervate capillary network.
-recurrent laryngeal nerve and external motor branch of superior laryngeal nerve
21
Thermal thyroid scans evaluate thyroid nodules as warm if they are ____ functioning, hot if they are ____ and cold if they are ____
normally, hyperfunctioning and hypofunctioning
24
What can reduce the progression of retinopathy?
Glycemic control & BP control
S17
What does a decrease in TSH cause?
What does an increase in TSH cause?
-decreased T3 & T4 synthesis, decreased follicular cell size, and decreased vascularity
-increase in TSH yields an increase in hormone production, gland cellularity and vascularity
23
What type of cells does the thyroid gland contain?
What is thyroglobulin?
parafollicular cells- which produce calcitonin
-thyroid is composed of follicles filled w/ thyroiglobulin, which is an iodinated glycoprotein and substrate for thyroid hormone synthesis
21
What 3 glands regulate thyroid function?
hypothalamus, pituitary, and thyroid glands, in a classic feedback control system
23
What are top 3 pathologies for hyperthyroidism?
Graves disease
toxic multinodular goiter
toxic adenoma
25
What is the best test of thyroid hormone action at cellular level?
What is normal TSH level
TSH assay
normal TSH level is 0.4-5.0 milliunits/L
24
s/s of hyperthyroidism?
T3 acts directly on what?
hypermetabolic state: sweating, heat intolerance & fatigue w/inability to sleep, osteoporosis and weight loss
T3 acts directly on the myocardium and peripheral vasculature to cause cardiovascular responses
25
We eat iodide, it is reduced in the GI tract and absorbed, then transported to follicular cells. Iodide then binds to thyroglobulin with the help of what enzyme?
After that, how do we form active T3, T4?
binding of iodide to thyroglobulin is catalyzed by an iodinase enzyme and yields inactive monoiodotyrosine and diiodotyrosine.
Then, T1 and T2 undergo coupling w/ thyroid peroxidase to form T3 and T4
22
In the blood, what 3 proteins do T4 and T3 reversibly bind to?
What’s T4/T3 ratio?
thyroxine-binding globulin (80%), prealbumin (10–15%), and albumin (5–10%).
10:1
22
What are HEENT s/s of Hyperthyroidism?
- Flushed face
- Fine hair
- Exophthalmos/proptosis
S26 table
What are
CV
GI
Skin
s/s of Hyperthyroidism?
CV: Palpitation
GI: Frequent BM/ Diarrhea
Skin: Warm, moist
S26 table
What are Neurogical s/s of Hyperthyroidism?
- Wasting, weakness, fatigue of proximal limb muscles
- fine tremor of hands
- hyperactive DTR (deep tendon reflexes)
S26 table
What are Cardiac effects of Hyperthyroidism?
- Tachycardia, arrythmias (atrial)
- Hyperdynamic
- ↑ C.O. and contractility
- Cardiomegaly
S26 table
What is the diagnosis that confirms Graves disease?
TSH antibodies in the context of
↓ TSH and ↑ T3 & T4
S27
What can enlarged goiter cause with Graves Disease?
- dysphagia
- globus sensation
- inspiratory stridor (from tracheal compression)
S27
What are s/s of Graves disease?
- diffusely enlarged thyroid
- Ophthalmopathy (in 30% cases)
- enlarged goiter
S27
Grave disease is ____, caused by thyroid-stimulating ____ that bind to ____ receptors, stimulating growth, vascularity, and hypersecretion
Grave disease is autoimmune, caused by thyroid-stimulating antibodies that bind to TSH receptors, stimulating growth, vascularity, and hypersecretion
S27
What is the leading cause of hyperthyroidism, effecting 0.4% population?
Who does this typically occurs in?
Graves disease
Typically occurs in
females (7:1 in 20-40 y/o)
S27
What is the 1st line treatment of Graves disease?
Antithyroid drug
Either Methimazole or Propylthiouracil (PTU)
S28
What treatment is recommended when medical treatments failed with Graves disease?
Ablative therapy or surgery
subtotal thyroidectomy > has lower incidence of hypothyroidism than radioactive iodine therapy
S28
What are complications from surgery for Graves disease?
- hypothyroidism
- hemorrhage with tracheal compression
- RLN (recurrent laryngeal nerve) damage
- damage to parathyroid glands
S28
What treatment for Graves disease is reserved for pre-op or thyroid storm and why?
high concentrations of iodine (this inhibits TH release)
The effect is short lived
S28
Pre-op considerations for Graves disease are:
____ ____should be established pre op
Elective cases may need to wait ____ weeks for antithyroid drugs to take effect
Thyroid levels should be established pre op
Elective cases may need to wait 6-8 weeks for antithyroid drugs to take effect
S29
What drugs are usually necessary in emergent cases of Graves disease?
- IV Beta-Blockers
- Glucocorticoids
- PTU
S29
Why do you need to evaluate upper airway of pt with Graves Disease pre-operatively?
for evidence of tracheal compression or deviation caused by a goiter
S29
What is a life-threatening exacerbation of hyperthyroidism precipitated by trauma, infection, medical illness, or surgery?
What is the mortality rate?
Thyroid Storm
20% mortality rate
S30
What kind of condition presents very similar to Thyroid storm and differentiation between the two can be extremely difficult?
Malignant Hyperthermia
S30
____ levels in thyroid storm may not be much higher than basic hyperthyroidism
Thyroid hormone
S30
When do Thyroid storm most often occurs?
postoperatively in untreated or inadequately treated hyperthyroid pts
S30
What are the treatments for Thyroid storm?
- rapid alleviation of thyrotoxicosis
- supportive care
S30
What is another name for Hypothyroidism?
What is the course of this disease in adults?
Myxedema
a slow, progressive course
S31
What are the lab results of primary Hypothyroidism?
↓ T3 & T4 production with adequate TSH
S31
What is the 1st common cause of Hypothyrodism?
What is the 2nd common cause?
1st common cause: ablation of the gland
(by radioactive iodine or sx)
2nd common cause: idiopathic and probably autoimmune
(antibodies blocking TSH receptors)
S31
What is an *autoimmune disorder *characterized by goitrous enlargement and hypothyroidism that usually affects middle-aged women?
Hashimoto thyroiditis
S31
What other syndrome commonly occurs with Hypothyroidism?
SIADH
S31
What are the general and psych symptoms of Hypothyroidism?
General symptoms:
-fatigue
-listlessness
-weight gain
Psych:
apathy
S31 and S32 table
What are the HEENT symptoms of Hypothyroidism?
- dry brittle hair
- large tongue
- deep hoarse voice
- periorbital edema
S31 and S32 table
What are the neurologic symptoms of Hypothyroidism?
- slow speech
- slowing of motor function
- prolonged relaxation phase of DTR
S31 and S32 table
What are the GI symptoms of Hypothyroidism?
- constipation
- slow GI function
- adynamic ileus may occur
S31 and S32 table
What are the skin symptoms of Hypothyroidism?
- pale
- cool
- dry
- thickened
- non-pitting peripheral edema
- cold intolerance
S31 and S32 table
what is the most common endocrine disease and how common is it?
Diabetes Mellitus
affects 1 in 10 adults
s4
What are the respiratory symptoms of Hypothyroidism?
- fluid overload
- pleural effusions
- dyspnea
S31
What are the cardiac effects of Hypothyroidism?
- ↓ C.O.
- Baroreceptor function impaired
- Hypothyroid cardiomyopathy
- Pericardial effusions
on EKG:
* Flattened or inverted T waves
* low-amplitude P waves & QRS complexes
* Sinus bradycardia
* Ventricular dysrhtymias
S31 and S32 table
Myxedema Coma is triggered by what type of pathologies?
- infection
- trauma
- cold
- CNS depressants
Slide 35
What is a rare form of hypothyroidism characterized by delirium, hypoventilation, hypothermia, bradycardia, HoTN, and severe dilutional hyponatremia?
Slide 35
Mxyedema
Coma
35
what is glucagon’s primary role?
stimulating glycogenolysis &gluconeogenesis, and inhibiting glycolysis
s3
what precedes onset of symptoms in type 1 DM?
long pre-clinical period (9-13 yrs) of B-cell antigen production
s5
Hypothermia is a ____feature that determine impaired thermoregulation
cardinal
Slide 35
Myxedema Coma occurs most commly in what population of patients
elderly women with a long history hypothyroidism?
Slide 35
Myexdema Coma is a medical emergency, What is the mortality percentage?
> 50%
Slide 35
What leads to diabetes mellitus?
and what does DM lead to w/ glucose?
an inadequate supply of insulin and/or an inadequate tissue response to insulin
- DM leads to increased circulating glucose levels with eventual microvascular and macrovascular complications
s4
What are treatments plan for Myxedema Coma
long list
- IV L-thyroxine
- IV L- triiodothyroine
- IV - hydration with glucose- saline solutions
- Tempature regulation
- Correction of electrolytes implance
- Stabliization of cardiac and pulmonary system
Slide 35
True or false: Mechanical ventilation is not frequently required
false, mechanical ventilation is frequently required
Slide 35
what is type 1A DM caused by?
T-cell–mediated autoimmune destruction of β cells within pancreatic islets resulting in minimal or absentcirculating levels of insulin
s4
what is type 1B DM?
rare disease of absolute insulin deficiency that is not immune mediated
s4
what happens in the initial stages of type 2 DM regarding insulin?
insensitivity to insulin on peripheral tissues leads to ↑pancreatic insulin secretion
s6
what is type 2 DM? is it immune mediated?
DM type 2 is not immune mediated
and results from defects in insulin receptors and post-receptor intracellular signaling pathways
s4
what are the key facts for type 1 DM regarding etiology?
is type 1 cause known?
- Accounts for 5-10% of all DM cases
- Usually diagnosed before age 40
Exact autoimmune cause of type 1a is unknown
s5
What are the 3 vitial signs that improve within 24 hours of given electrolyte ?
- Heart Rate
- BP
- Temp
Slide 35
Swelling of thyroid gland determine by hypertrophy & hyperplasia of follicular epithelium can be define as a……
Goiter & Thyroid Tumors
Slide 36
What are the causes of Goiter & Thyroid Tumors?
- lack of iodine
- ingestion of goitrogen (cassava,phenylbutazone, lithium)
- defect in the hormonal biosynthetic pathway
Slide 36
Goiter and Thyroid Tumors are assoicated with what type of compenstated state?
Euthyroid
Slide 36
Goiter and Thyriod Tumors are treated with what type of medication in most cases?
L-thyroxine
Slide 36
When is surgery indicated for a Goiter and thyroid Tumors?
- medical therapy is ineffective
- compromises of air way
- cosmetically unacceptable
Slide 36
What pathology during pre-op history would be predictive of possible airway obstruction during general anesthesia?
dyspnea in upright or supine postition
Slide 37
what is hyperglycemia over several days/weeks associated with in type 1 DM?
fatigue, weight loss, polyuria, polydipsia, blurry vision, hypovolemia, ketoacidosis
- she mentioned POLYURIA loudly lol
s5
how much of b cell function is lost before hyperglycemia even shows up in type 1 DM?
At least 80-90%
s5
What imaging testing is used to examine and assess the extent of the tumor?
CT
Slide 37
Which pulmoary funtion test is used to demonstrate the site and degree of obstruction?
The test is given with the patient in what 2 positions?
- FLow - volume loop
- upright and supine postition
Slide 37
as type 2 DM progresses, what happens to pancreas and insulin levels?
pancreatic function decreases & insulin levels become inadequate
s6
what are the 3 main abnormalities in DM2?
- ↑hepatic glucose release caused by a reduction in insulin’s inhibitory effect on liver
- Impaired insulin secretion
- Insufficient glucose uptake in peripheral tissues
s6
____ in the inspiratory limb of the loop indicate ____-thoracic obstruction
____ flow in the expiratory limb indicates an ____-thoracic obstruction
- Limitations, extra-thoracic obstructions
- Delayed, intra-thoracic obstructions
Slide 37
what’s 2 tests are used for the diagnosis for DM2?
fasting blood glucose and HbA1c
s7
what is DM2 characterized by?
insulin resistance in skeletal muscle, adipose & liver
s7
what are the 3 causes of insulin resistance?
what may also contribute regarding lifestlye?
- Abnormal insulin molecules
- Circulating insulin antagonists
- Insulin receptor defects
OBESITY AND SEDENTARY LIFESTYLE also contribute!
s7
What type of imaging test can be adminstered to a patient who has a goiter or thyroid tumor in an upright and/or supine position to indicate the degree of cardiac compression ?
Echocardiogram
Slide 37
what HbA1c is considered normal?
prediabetic?
diabetic?
normal: <5.7%
prediabetic: 5.7-6.4%
diabetic: >/= 6.5%
s8
what is the american diabetes assoc criteria for dx of diabetes?
- A1c >/= 6.5
- Fasting Plasma Glucose >/= 126 mg/dL (7.0 mmol/L)* and fasting for at least 8 hrs!*
- 2-hr plasma gluc >/= 200 mg/dL during glucose tolerance test
- *in pt with classic symptoms of hyperglycemia or hyperglycemia crisis a random plasma gluc of >/= 200 mg/dL
s8
What is the morbidity percentage regarding thyroid surgery?
13%
Slide 38
what is the DM2 treatment? (3 things)
- Dietary adjustments
- Exercise/weight loss
- PO antidiabetic drugs - metformin (preferred initial med tx) and/or sulfonylureas
s9
Right laryngeal nerve injury can be____ or bilateral and temporary or ____.
- unilateral
- permanent
38
what drug class is metformin? and how does it help DM2?
A biguanide - preferred initial drug tx
* Enhances glucose transport into tissues
* ↓TGL & LDL levels
s9
what do sulfonylureas do?
what are some side effects?
- stimulate insulin secretion
- Enhances glucose transport into tissues
SE’s include hypoglycemia, weight gain & cardiac effects
s9
why are sulfonylureas not effective long term?
- d/t diabetic progressive loss of B cell function
s9
Parathyroid dysfx ::
- The ___ parathyroid glands are behind upper & lower poles of the thyroid gland + produce _______, which is released into the circulation by a _________ feedback that depends on plasma _______ level
- __________ stimulates the release of PTH
- ___________ suppresses hormonal synthesis and release
- PTH maintains normal plasma calcium level by promoting the movement of calcium across ________, __________, and ________.
4 … parathyroid hormone (PTH) … negative … calcium
Hypocalcemia
hypercalcemia
GI tract, renal tubules, and bone
53
Hyperparathryoidism ::
- Present when secretion of PTH is ________
- Serum calcium concentrations may be _______, ______, or ______
- Hyperparathyroidism is classified as _____, ______, or _______
increased
increased, decreased, or unchanged
primary, secondary, or ectopic
54
ACTH- Independent Cushing: _____ cortisol production by abnormal _________ tissue that is not regulated by ____ and ACTH.
- excessive
- adrenocortical
- CRH
44
Acute Ectropic ACTH syndrome is a form of ACTH -_______ Cushing that is the most often associated with _______ __________ __________ carcinoma.
- dependent
- Small Cell Lung
44
In ACTH- Independent Cushing:
* CRH and ACTH levels are _________
* ______ or ______ ______ tumors are the most common cause of ACTH-independent Curshing Syndrome.
- suppressed
- Benign or Malignant Adrenocortical
44
Secondary Hyperparathyroidism ::
__________ response of the parathyroid glands to counteract a separate disease process producing _________ s/a CRF
o adaptive, it seldom produces ____________
o Tx ?? (2)
compensatory … hypocalcemia
hypercalcemia
treat underlying cause
phosphate binder - renal pts to normalize serum phos
55
Symptoms of Hypercortisolism (Cushing Syndrome) are:
* Sudden weight ____.
* ↑_______ fat (______ face)
* Ecchymoses
* HTN
* ______________ intolerance
* muscle __________
* depression
* insomnia
- weight gain
- facial
- Moon
- intolereance
- wasting
45
Hypoparathyroidism ::
- Present when PTH is_________ or peripheral tissues are_________ to its effects
- Absence or deficient PTH is almost always__________, reflecting inadvertent removal of parathyroid glands, as during _____
- Pseudohypoparathyroidism is a________ disorder where PTH is adequate, but the ________ are unable to respond to it
deficient … resistant
iatrogenic … thyroidectomy
congenital … kidneys
56
Diagnosis of Hypercortisolism (Cushing Syndome is done with ___ hour urine ______.
- 24 hour urine cortisol
45
Distinguishing Cushings ACTH Dependent from ACTH Independent involves measuring ________ ACTH and ________________ assays.
- plasma
- immunoradiometric
45
A high-doses dexamethasone suppression test distringuishes _______ from ______ ACTH Syndrome.
- Cushing’s
- Ectopic
45
In Hypercortisolism (Cushing Syndrome) Imaging is useful for determining tumor ______________, but isn’t helpfu if gauging _________ function.
- location
- adrenal
45
Treatment of choice for Hypercortisolism (Cushing Syndrome):
* transsphrenoidal _______________ if ________ is resectable.
* Alternatively, 85-90% resection of the _______ pituitary.
- microadrenomectomy
- microadenoma
- anterior pituitary
46
Hypercortisolism (Cushing Syndrome): Surgical adrenolectomy is the treatmetn for adrenal __________ or ___________.
- adenoma
- carcinoma
46
Pituitary ________ and bilateral total ___________ are necessary for some patients with Cushings.
- irradation
- adrenalectomy
46
Pre-Op Considerations for Cushing Syndome:
* evaluate/treat ____,
* ______ balance
* blood glucose
* Consider ____________ in position
- BP
- Electrolye
- Osteoporosis
46
Name the (8) Classic Signs of Cushings Syndome:
* Fat Pad: _____ ______
* ______ face
* Extra _____ and body hair
* Thin skin– _______
* ______ arms and legs
* ______ Cheeks
* _________ hair
* Stretch ______
- Buffalo Hump
- Moon Face
- Face
- bruising
- thin
- red
- marks
47
Hyperaldosteronims (Conn Syndrome) is the _______ secretion of _________ from a functional ______ that acts __________ of a physiologic stimulus.
- excessive
- tumor
- independently
48
Hyperaldosteronims (Conns Syndrome)
* _____ > ______
* Occasionally associated with ______________, _________________ or acromegaly.
- women>men
- Pheochromocytoma
- hyperparathyroidism
48
Secondary Hyperaldosteronism: presents when serum _______ is increased, stimulating the release of _____________.
- renin
- aldosterone
48
What does the TRH stumulation test assess?
functional state of the TSH-secreting mechanism, and is used to test pituitary function
24
Symptoms of Hyperaldosteronism (Conns Syndrome):
* _______
* _________kalemia
* hypokalemia _______ ________-
- HTN
- Hypokalemia
- Hypokalemia metabolic alkalosis
48
Hyperaldosteronism (Conn Syndrome) is diagnosised with Spontaneous _______ in presense of systemic ______.
- hypokalemia
- HTN
49
In Primary Hyper-Aldosteronism, plasma _____ activity is ______.
- renin
- supressed
49
In Seconday Hyper-Aldosteronism the plasma ______ activity is ______.
- renin
- high
49
Long-term ingestion of _____ can cause a syndrome that mimics the features of ______________________. Which include HTN, __________ and suppression of ______.
- licorice
- hyperaldosteronism
- hypokalemia
- RAAS
49
Hyperaldosteronism (Conn Syndrome):
* Competetive aldosterone antagonist (________)
* _____ replacement
* antihypertensives
* diuretics
* ________ removal
* possible _______________
- Spironolactone
- Potassium
- tumor
- adrenalectomy
49
Hypoaldosteronism is ________ in the absence of ________ insufficiency.
- hyperkalemia
- renal
50
Hypoaldosteronism:
* Hyperkalemia may be enhanced by ________.
* _________ metabolic acidosis is common.
- hyperglycemia
- Hypercholemic
50
Hypoaldosteronism patients may experience ____ _____ d/t hyperkalemia, ________ HoTN, and ___________
- heart block
- orthostatic
- hyponatremia
50
Hypoaldosteronims lack of aldosterone may be caused by ________ deficiency of aldosterone synthetase or hypoeninemia d/t defects in the ________ apparatus or _______ inhibitors.
- congential
- juxtaglomerular
- ACE
50
Hyporeninemic Hypoaldosteronism typically occus in pts > ____ years old with Chronic ________ failure or _______ _______.
- 45 years
- Renal
- Diabetes Mellitus
50
__________ - induced ________ deficiency is a reversible cause of Hyporeninemic Hypoaldosteronism.
- Imadomethacin
- prostaglandin
50
Treatment of Hypoaldosteronism includes liberal _____ intake and daily administration of ____________.
- Sodium
- fludrocortisone
50
Name the (2) types of Adrenal Insufficency
- Primary
- Seconday
51
Primary Adrenal Insufficency is known as ______ disease
Addisons
51
Primary Arenal Insufficency (Addison dz) is when adrenal glands unable to produce enough ________, ___________ and adrogen hormones.
- glucocorticoid
- mineralcorticoid
51
What is the most common cause of autoimmune adrenal destruction.
- Primary Adrenal Insufficiency (Addison)
51
In Primary Adrenal Insufficiency (Addison) >____% of the gland must be involved before signs appear.
90%
51
Secondary Adrenal Insufficiency: ______________ -pituitary dz or suppression leading to _______ in the production of CRH or ACTH.
- hypothalmic
- failure
51
Seconday Adrenal Insufficency is a deficiency of ________, while Primary (Addison) Adrenal Insufficency is a deficency in glucocorticoid, mineralocorticoid and _________ hormones.
- glucocorticoid
- adrenal
51
Seconday Adrenal Insufficency is caused by _______, such as with the use of synthetic glucocorticoids, _________ surgery or ___________.
*iatrogenic
* pituitary surgery
* radiation
51
Seconday Adrenal Insufficency patients lack _________ and may demonstrate only mild ________ abnormalities.
- hyperpigmentation
- electrolyte
51
Adrenal Insufficiency diagnosis is baseline cortisol <____ ug/dL and remains <____ after ACTH stimulation
- <20
- <20
52
Adrenal Insufficeny postive test demonstrates a ______ response to _______ and indicates an _________ of the adrenal.
- poor
- ACTH
- impairment
Absolute Adrenal Insufficency is characterized by a ______ baseline cortisol and a ______ ACTH stimulation test.
- low
- postitive
52
Relative Adrenal Insufficency is indicated by a ______ baseline cortisol and a _______ ACTH test.
- high
- positive
The treatment of Adrenal Insufficiency is _________.
Steroids.
52
Pituitary gland is located in the ______ ______ + consists of Anterior + Posterior
The ANTERIOR pituitary secretes 6 hormones under control of the ________.
** name them
Over production of these hormones often assocaited with hyper secretion of _____ (cushing’s) by anterior pituitary _________-
______ and ________ are made in hypothalamus + stored in POSTERIOR pituitary
To release these 2 hormones , stimulate the __________ in the hypothalamus that sense plasma osmolarity.
Sella Turcica
Hypothalamus
GH, ACTH, TSH, FSH, LH, Prolactin
ACTH … adenomas
vasopressing (ADH) + oxytocin
osmoreceptors
57
ACROMEGALY ::
is d/t excessive secretion of ____ _______ + most common cause is ________ in ANT pituitary gland
**Treatment? (2)
*Serum insulin-like growth factor 1 is ________
*What test measures plasma growth hormone ?
*Overgrowth of soft tissue makes pt susceptible to … ?
*Overgrowth of surrounding cartilagenous structures can cause ? (3)
*______ ________ is common d/t nerve trapping by connective tissues
growth hormone … adenoma
Tx = transphenoidal surgical excision of adenoma .. OR .. LA somatostatin analogue (if can’t operate)
*elevated
*Oral glucose tolerance test – elevated GH above 1 after 2 hrs of ingesting 75g glucose
*Upper airway obstruction
*hoarseness … abnormal movement of vocal cords .. RLN paralysis
*Peripheral Neuropathy
58
ACROMEGALY ANESTHESIA IMPLICATIONS ::
*difficult mask ventilation d/t _______________
*enlarged ________ and ______ predisposes to upper airway obstructions + interferes with _______ _____ visualizations during DL.
*increased distance bw lips + vocal cords d/t ______ ______
*Glottic opening may be narrowed d/t ______ ___ __________
*May require smaller ______ , video larygoscopy , or _____ ______ induction
*distorted facial anatomy
*tongue + epiglottis … vocal cord
*mandible overgrowth
*vocal cord enlargement
* ETT … awake fiberoptic
58
SIADH ::
Treatment ? (4)
Hyponatremia treated with ____ _____ raising it less than within 24 hrs?
*fluid restriction , salt tablets ,, loop diuretics ,, vasopressin antagonists
*hypertonic saline @ <8 mEq/L within 24 hrs
60
What can happen to the patients airway if they expereince unilateral trauma to the thryoid?
How long does it take the thyroid to return to normal?
- hoarseness but no airway obstruction
- function return in 3-6 months
Slide 38
What causes permanent hoarsness for a patient after thyriod surgery?
Ligation or transection of the nerve
Slide 38
How does bilateral traurma effect the patient after surgery?
- cause airway obstructin
- difficulty coughing
- may warrant tracheostomy
Slide 38
Hypoparathyriodism due to thyriod surgery is caused by?
inadvertent parathyroid damage
Slide 38
What is a sign and / or symptom of hypoparathyroidism that takes place 24-48 hours postoperativiely?
hypocalcemia
Slide 38
What complication from thyroid surgery can lead to tracheal compression?
Hemoatoma
A trach-set should be kept at bedside during immediate postop period
Slide 38
What are the structures found within the adrenal gland?
- cortex
- medulla
slide 39
What steroids and / or hormones are synthesizes in the cortex?
- glucocorticoids
- mineralocorticoids (aldosterone)
- androgens
Slide 39
Pertaining to Adrenal Gland function ::
Hypothalamus sends ____ to the anterior pituitary, which stimulates ____ release from the anterior pituitary
- corticotropin-releasing hormone (CRH)
- corticotropin (ACTH)
Slide 39
Corticotropin is release from the anterior pituitary to stimulate the adrenal cortex to produce, ____.
Cortisol
Slide 39
Cortisol facilitate conversion of ___ to ___ .
This takes place in what part of the adrenal gland?
- norepinephrine to epinphrine
- adrenal medulla
Slide 39
How does cortisol effects glucose in the body?
- induces hyperglycemia
- reflectinggluconeogenesis
- inhibition of glucose uptake by cells
39
What hormones casuses sodium retention and potassium excretion?
cortisol
aldosterone
Slide 39
What is a pheochromocytoma?
a catecholamine-secreting tumor that arise from chromaffin cells of the sympathoadrenal system
40
Uncontrolled catecholamine release can lead to what disease process?
- malignant HTN
- CVA
- MI
slide 40
____% are an isolated finding
____% inherited (familial)
90%
10%
Slide 40
____% occur in the adrenal medulla,
____% in organ of Zuckerkandle,
____% neck/thorax
80%
18%
2%
Slide 40
Malignant Pheochromocytoma spread to through what body system’s
venous system
lymph systems
Slide 40
What is the ratio of NE:EPI that is secrete by adrenal medulla with at patient that has Pheochromocytoma?
NE:EPI , 85:15
inverse of normal adrenal secretion
Slide 40
Some pheochromocytoma secrete higher levels of ____and, more rarely, ____
epi
dopamine
Slide 40
How long can a pheochromocytoma attack last?
between 1min and several hours
maybe occasional to frequent
41
How does the pheochromocytoma attacks occur?
- spontaneously
- triggered by injury, stress, or meds
Slide 41
What are the signs and symptoms of pheochromocytoma?
- pallor
- sweating
- palpitations
- orthostatic hypotension
- cornary vasoconstriction
- cardiomyopathy
- CHF
- EKG changes
Slide 41
What are some tests that are utilize to diagnose pheochromocytoma?
- 24h urine collection
- CT & MRI
- I-metaiodobenzylguanidine (MIBG) scintigraphy
localize the tumor
Slide 41
A 24 hour urine collection test for a pateint that has pheochromocytoma will be postive what to substances?
metanephrines catecholamines
Slide 41
What are some pre -op consideration to take into acconut for with patients who have a pheochromocytoma?
- α blocker to lower BP
- decrease intravascular volume
- allow sensitization of adrenergic receptors
- decrease myocardial dysfunction
Slide 42
What is the most frequently used preop Alpha blocker for phepchromocytoma?
Phenoxybenzamine
a noncompetitive α1 antagonist with some α2-blocking properties
Slide 42
What other medication can be use to treat pheochromocytoma?
Prazosin
doxazosin
pure α1 blockers, shorter acting w/ less tachycardia
Slide 42
True or false: Tachycardia after an α blockade should be treated with a BB.
True
Slide 42
True or false: Give a selective BB before α blocker b/c blocking vasodilatory β2 receptors results in unopposed α agonism, leading to vasoconstriction and hypertensive crises
False: Never give nonselective BB before α blocker b/c blocking vasodilatory β2 receptors results in unopposed α agonism, leading to vasoconstriction and hypertensive crises
Slide 42
What other class of blood pressure medication is use to control HTN for patients with pheochromocytoma?
CCBs
Slide 42
DIABETES INSIPIDUS ::
Symptoms?
Initial treatment?
Neurogenic treatment?
Nephrogenic treatment?
Anesthesia?
*polydipsia , increased serum osmo , dilute urine
*IV electrolytes
*DDAVP
*low-salt , low-protein , diuretics , NSAIDs
*monitor UOP + lytes
60
DIABETES INSIPIDUS ::
reflects absence of _________
*caused by destruction of _______ _________ (neurogenic)
*caused by failure of _______ ________ to respond to ADH (nephrogenic)
* the two types are differentiate based on responses to _________
»» this causes urine concentration in _______ type
*vasopressin
*posterior pituitary
*renal tubules
*desmopressin
*neurogenic
60
SYNDROME OF INAPPROPRIATE ADH ::
occurs in diverse pathologies like …? (4)
elevated ADH most likely to occur following ______ ________
Sx - increased urine _____ and _______ … in presence of _______ and decreased serum _________
Decrease in sodium can result in ______ ______ and _____
*intracranial tumors, hypothyroidism, porphyria, lung carcinoma
*major surgeries
*sodium and osmolarity … hyponatremia … osmolarity
*cerebral edema + seizures
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